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We assessed the risk factors for major amputation of diabetic foot ulcers (DFUs) in patients with diabetic kidney disease (DKD) stages 3b–5. For DFU assessment, in addition to DFU location and presence of infection, ischemia, and neuropathy, vascular calcification was assessed using the medial arterial calcification (MAC) score. Of 210 patients, 26 (12.4%) underwent major amputations. Only the location and extension of DFU, represented by Texas grade differed between the minor and major amputation groups. However, after adjusting for covariates, ulcer location of mid- or hindfoot (vs. forefoot, odds ratio [OR] = 3.27), Texas grades 2 or 3 (vs. grade 0, OR = 5.78), and severe MAC (vs. no MAC, OR = 4.46) was an independent risk factor for major amputation (all P < 0.05). The current use of antiplatelets was a possible protective factor for major amputations (OR = 0.37, P = 0.055). In conclusion, DFU with severe MAC is associated with major amputation in patients with DKD.
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Background@#Although an inverse association between the N-terminal prohormone brain natriuretic peptide (NT-proBNP) and obesity exists, only few major studies have assessed the association between NT-proBNP levels and skeletal muscle mass in asymptomatic healthy adults. Therefore, this cross-sectional study was conducted. @*Methods@#We assessed participants who underwent health examinations at Kangbuk Samsung Hospital in South Korea from January 2012 to December 2019. Appendicular skeletal muscle mass was measured using a bioelectrical impedance analyzer, and the skeletal muscle mass index (SMI) was calculated. Participants were divided into the control, mildly low skeletal muscle mass (LMM) (−2 standard deviation [SD] < SMI ≤−1 [SD]), and severely LMM groups (SD ≤−2) based on their SMI. The association between elevated NT-proBNP level (≥125 pg/mL) and skeletal muscle mass was assessed using multivariable logistic regression analysis with adjustment for confounding factors. @*Results@#This study enrolled 15,013 participants (mean age, 37.52±9.52; men, 54.24%; control, n=12,827; mildly LMM, n=1,998; severely LMM, n=188). Prevalence of elevated NT-proBNP was higher in mildly and severely LMM groups than in the control group (control, 1.19%; mildly LMM, 1.4%; severely LMM, 4.26%; P=0.001). The adjusted odds ratio (OR) of elevated NT-proBNP was significantly higher in severely LMM (OR, 2.87; 95% confidence interval [CI], 1.3 to 6.37) than in control (OR, 1.00; reference) or mildly LMM groups (OR, 1.24; 95% CI, 0.81 to 1.89). @*Conclusion@#Our results showed that NT-proBNP elevation were more prevalent in participants with LMM. In addition, our study showed an association between skeletal muscle mass and NT-proBNP level in a relatively young and healthy adult population.
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Freiberg disease, known as a Freiberg infraction, is an uncommon disorder of the second metatarsal head of the foot. Conservative treatment is recommended as initial management to relieve symptoms and minimize epiphyseal deformity. However, due to the rarity of this disorder, there have been few reports of long-term clinical and radiologic follow-ups of Freiberg disease treated with conservative treatment. We report Freiberg disease treated with conservative management including modification of shoe and insole. A 24-year-old woman presented with right forefoot pain. In plain radiography, the sunken appearance of the metatarsal head and periarticular spurring was observed. The articular cartilage was intact in magnetic resonance imaging (MRI), corresponding to Smillie’s stage 3 and Thompson’s type 2. We prescribed carbon fiber insert, customed semirigid insole with metatarsal dome and rocker-bottom shoe to relieve pressure under the metatarsal heads. Freiberg disease maintained a well-tolerable condition during 2-year follow-up period without further progression in MRI.
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Displaced intra-articular calcaneal fractures are difficult to treat because of complex anatomy and high soft tissue complications. Various surgical approaches have been introduced to solve these problems, but the treatment remains complex. Recently, clinically and radiographically superior results were reported using a subtalar arthroscopy in reducing the posterior facet in both percutaneous and open approaches. In the percutaneous approach, the arthroscopically assistant percutaneous approach must be selected carefully for mild-tomoderately displaced fractures because of the limited view. In the open approach, there is little evidence of the utility of subtalar arthroscopy. Therefore, intraoperative arthroscopy should always be used in conjunction with fluoroscopy to achieve reduction and assess the internal fixation placement.
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Objective@#To identify factors associated with swallowing recovery in patients with dysphagia after ischemic stroke. @*Methods@#Patients admitted to Kangbuk Samsung Hospital from 2011 to 2019 for first acute ischemic stroke and dysphagia, as confirmed by a videofluoroscopic swallowing study (VFSS), were enrolled in this retrospective study. Patients whose Dysphagia Outcome and Severity Scale (DOSS) level was ＜6 as determined by VFSS were monitored in a dysphagia clinic and additional VFSS was performed periodically until one year after stroke. Follow-up was discontinued when the DOSS level reached 6 or 7. The main study outcomes were full recovery and tube removal rate. Cox regression analysis was used to identify prognostic factors of dysphagia. The Kaplan-Meier method was used to generate curves of the proportions of patients that achieved full recovery. @*Results@#One hundred and thirteen patients were enrolled. Multivariate analysis showed that only initial DOSS was significantly associated with swallowing recovery (13.0% for non-oral feeding vs. 35.6 % for a modified diet). @*Conclusion@#Initial swallowing status (as determined by VFSS findings) is strongly associated with swallowing recovery in post-ischemic stroke patients. Assessments of dysphagia are important for predicting dysphagia recovery and planning management strategies.
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Background@#Homocysteine has been drawing attention with a closed linkage with skeletal muscle. However, the association of hyperhomocysteinemia with decreased skeletal muscle mass remains unclear. We aimed to investigate the association of hyperhomocysteinemia with low skeletal muscle mass (LMM) in asymptomatic adults. @*Methods@#This was a cross-sectional study of 114,583 community-dwelling adults without cancer, stroke, or cardiovascular diseases who underwent measurements of plasma homocysteine and body composition analysis from 2012 to 2018. Hyperhomocysteinemia was defined as >15 μmol/L. Skeletal muscle mass index (SMI) was calculated based on appendicular muscle mass (kg)/height (m)2. Participants were classified into three groups based on SMI: “normal,” “mildly low,” and “severely low.” @*Results@#The prevalence of hyperhomocysteinemia was the highest in subjects with severely LMM (12.9%), followed by those with mildly LMM (9.8%), and those with normal muscle mass (8.5%) (P for trend <0.001). In a multivariable logistic regression model, hyperhomocysteinemia was significantly associated with having a mildly LMM (odds ratio [OR], 1.305; 95% confidence interval [CI], 1.224 to 1.392) and severely LMM (OR, 1.958; 95% CI, 1.667 to 2.286), respectively. One unit increment of log-transformed homocysteine was associated with 1.360 and 2.169 times higher risk of having mildly LMM and severely LMM, respectively. @*Conclusion@#We demonstrated that elevated homocysteine has an independent association with LMM in asymptomatic adults, supporting that hyperhomocysteinemia itself can be a risk for decline in skeletal musculature.
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Purpose@#This study sought to investigate the appropriate indications for intra-articular injection of hyaluronic acid in ankle osteoarthritis, its efficacy at each stage of osteoarthritis and to compare the efficacy related differences at each stage. @*Materials and Methods@#A retrospective study was conducted from January 2016 to September 2019 on 43 patients (50 cases) diagnosed with ankle arthritis and given intra-articular injection of hyaluronic acid. Patients were classified according to the modified Takakura ankle osteoarthritis stages. Stage 2 comprised 24 cases; stage 3A, 15 cases; stage 3B, 8 cases; and stage 4, 3 cases. The clinical evaluation was carried out using the visual analogue scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) score, and the Foot and Ankle Outcome Score (FAOS). The patients’ satisfaction with the injection was evaluated at 1 year after injection. A radiographic evaluation was performed to gauge the progression of osteoarthritis before and after the injection. @*Results@#The VAS, AOFAS score, and FAOS at 3 months and 1 year after injection showed statistically significant improvements compared to those before the injection. There was a significant difference in the VAS for each stage over time; however, this was not the case with the AOFAS score and the FAOS. A significant improvement of the VAS after injection was seen only in stage 3A when compared with the other stages. The overall satisfaction rate with the injection was 90%. There were no ankle osteoarthritic stage changes in the serial follow-up radiograph. @*Conclusion@#Intra-articular injection of hyaluronic acid resulted in a significant clinical improvement up to 1 year after the injection.Therefore, the intra-articular injection of hyaluronic acid could be a treatment option for ankle osteoarthritis.
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Excessive salt intake induces hypertension, but several gamma-aminobutyric acid (GABA) supplements have been shown to reduce blood pressure. GABAsalt, a fermented salt by L. brevis BJ20 containing GABA was prepared through the post-fermentation with refined salt and the fermented GABA extract. We evaluated the effect of GABA-salt on hypertension in a high salt, high cholesterol diet induced mouse model. We analyzed type 1 macrophage (M1) polarization, the expression of M1 related cytokines, GABA receptor expression, endothelial cell (EC) dysfunction, vascular smooth muscle cell (VSMC) proliferation, and medial thicknesses in mice model. GABA-salt attenuated diet-induced blood pressure increases, M1 polarization, and TNF-α and inducible nitric oxide synthase (NOS) levels in mouse aortas, and in salt treated macrophages in vitro. Furthermore, GABA-salt induced higher GABAB receptor and endothelial NOS (eNOS) and eNOS phosphorylation levels than those observed in salt treated ECs. In addition, GABA-salt attenuated EC dysfunction by decreasing the levels of adhesion molecules (E-selectin, Intercellular Adhesion Molecule-1 [ICAM-1], vascular cell adhesion molecule-1 [VCAM-1]) and of von Willebrand Factor and reduced EC death. GABA-salt also reduced diet-induced reductions in the levels of eNOS, phosphorylated eNOS, VSMC proliferation and medial thickening in mouse aortic tissues, and attenuated Endothelin-1 levels in salt treated VSMCs. In summary, GABA-salt reduced high salt, high cholesterol diet induced hypertension in our mouse model by reducing M1 polarization, EC dysfunction, and VSMC proliferation.
ABSTRACT
Excessive salt intake induces hypertension, but several gamma-aminobutyric acid (GABA) supplements have been shown to reduce blood pressure. GABAsalt, a fermented salt by L. brevis BJ20 containing GABA was prepared through the post-fermentation with refined salt and the fermented GABA extract. We evaluated the effect of GABA-salt on hypertension in a high salt, high cholesterol diet induced mouse model. We analyzed type 1 macrophage (M1) polarization, the expression of M1 related cytokines, GABA receptor expression, endothelial cell (EC) dysfunction, vascular smooth muscle cell (VSMC) proliferation, and medial thicknesses in mice model. GABA-salt attenuated diet-induced blood pressure increases, M1 polarization, and TNF-α and inducible nitric oxide synthase (NOS) levels in mouse aortas, and in salt treated macrophages in vitro. Furthermore, GABA-salt induced higher GABAB receptor and endothelial NOS (eNOS) and eNOS phosphorylation levels than those observed in salt treated ECs. In addition, GABA-salt attenuated EC dysfunction by decreasing the levels of adhesion molecules (E-selectin, Intercellular Adhesion Molecule-1 [ICAM-1], vascular cell adhesion molecule-1 [VCAM-1]) and of von Willebrand Factor and reduced EC death. GABA-salt also reduced diet-induced reductions in the levels of eNOS, phosphorylated eNOS, VSMC proliferation and medial thickening in mouse aortic tissues, and attenuated Endothelin-1 levels in salt treated VSMCs. In summary, GABA-salt reduced high salt, high cholesterol diet induced hypertension in our mouse model by reducing M1 polarization, EC dysfunction, and VSMC proliferation.
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Purpose@#The purpose of this study is to evaluate the results of Kidner procedure combined with medial displacement calcaneal osteotomy (MDCO) in patients with the symptomatic accessory navicular with hindfoot valgus. @*Materials and Methods@#From January 2014 to January 2019, fifteen patients (15 cases) who had undergone a Kidner procedure combined with MDCO for symptomatic accessory navicular with hindfoot valgus were included. Their mean age was 36.3 years old (19∼61 years old) and there were 6 males and 9 females. The clinical results were evaluated using visual analogue scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) midfoot score, and postoperative subjective satisfaction. The radiographic results were evaluated using the talonavicular coverage angle and the anteroposterior talo-first metatarsal angle, the lateral talo-first metatarsal angle, the calcaneal pitch angle, and the hindfoot alignment angle. The postoperative complications were also evaluated. @*Results@#The VAS and AOFAS midfoot scores continuously improved until 12 months after surgery. Subjective satisfaction after surgery was excellent in 10 cases and good in 5 cases. The hindfoot alignment angle significantly changed after surgery. Pain due to lateral impingement disappeared in five patients, and persisted in one patient. Five patients complained of irritation caused by their fixation devices, and all the symptoms improved after removal of the fixation devices. @*Conclusion@#Kidner procedure combined with MDCO in patients with the symptomatic accessory navicular with hindfoot valgus showed good clinical results with satisfactory correction of hindfoot valgus. In particular, the clinical results showed continuous improvement until 12 months after surgery.
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Background/Aims@#Inflammatory bowel disease (IBD) is an autoimmune disease characterized by chronic inflammation mainly in the large intestine. The interleukin-10 knockout (IL-10 KO) mouse is a well-known animal model of IBD that develops spontaneous intestinal inflammation resembling Crohn’s disease. Oxidative stress is considered to be the leading cause of cell and tissue damage. Reactive oxygen species (ROS) can cause direct cell injury and/or indirect cell injury by inducing the secretion of cytokines from damaged cells. This study evaluated the effects of mesenchymal stem cell (MSC) on the progression of IBD. @*Methods@#In this study, human bone marrow-derived MSCs were injected into IL-10 KO mice (MSC). Oxidative stress and inflammation levels were evaluated in the large intestine and compared with those in control IL-10 KO mice (CON) and normal wild-type control mice (Wild). @*Results@#The levels of ROS (superoxide and hydrogen peroxidase) and a secondary end-product of lipid peroxidation (malondialdehyde) were considerably higher in the CON, while superoxide dismutase and catalase levels were lower in the MSC. Inflammation-related marker (interferon-γ, tumor necrosis factor-α, IL-4, and CD8) expression and inflammatory histological changes were much less pronounced in MSC than in CON. @*Conclusions@#MSCs affect the redox balance, leading to the suppression of IBD.
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Rapidly destructive arthrosis is a rare syndrome characterized by narrowing of the joint space and rapid joint destruction within 6∼12 months. A 62-year-old woman with anaplastic lymphoma kinase rearranged non-small-cell lung cancer presented with both knee pain and varus deformity. She was treated with crizotinib 500 mg/day for more than 2 years, with partial tumor response. Initial plain radiography showed Kellgren and Lawrence (K-L) grade 1. After 10 months, varus deformity was worsened and plain radiography aggravated to K-L grade 4 despite conservative treatment including activity modification.Diffuse synovitis with massive joint effusion and destruction of anterior cruciate ligament, medial meniscus, medial collateral ligament, and lateral collateral ligament were shown in magnetic resonance imaging. The patient was diagnosed with rapidly destructive arthrosis of knee and underwent a both total knee arthroplasty.
ABSTRACT
Rapidly destructive arthrosis is a rare syndrome characterized by narrowing of the joint space and rapid joint destruction within 6∼12 months. A 62-year-old woman with anaplastic lymphoma kinase rearranged non-small-cell lung cancer presented with both knee pain and varus deformity. She was treated with crizotinib 500 mg/day for more than 2 years, with partial tumor response. Initial plain radiography showed Kellgren and Lawrence (K-L) grade 1. After 10 months, varus deformity was worsened and plain radiography aggravated to K-L grade 4 despite conservative treatment including activity modification.Diffuse synovitis with massive joint effusion and destruction of anterior cruciate ligament, medial meniscus, medial collateral ligament, and lateral collateral ligament were shown in magnetic resonance imaging. The patient was diagnosed with rapidly destructive arthrosis of knee and underwent a both total knee arthroplasty.
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Forefoot disorders are often seen in clinical practice. Forefoot deformity and pain can deteriorate gait function and decrease quality of life. This review presents common forefoot disorders and conservative treatment using an insole or orthosis. Metatarsalgia is a painful foot condition affecting the metatarsal (MT) region of the foot. A MT pad, MT bar, or forefoot cushion can be used to alleviate MT pain. Hallux valgus is a deformity characterized by medial deviation of the first MT and lateral deviation of the hallux. A toe spreader, valgus splint, and bunion shield are commonly applied to patients with hallux valgus. Hallux limitus and hallux rigidus refer to painful limitations of dorsiflexion of the first metatarsophalangeal joint. A kinetic wedge foot orthosis or rocker sole can help relieve symptoms from hallux limitus or rigidus. Hammer, claw, and mallet toes are sagittal plane deformities of the lesser toes. Toe sleeve or padding can be applied over high-pressure areas in the proximal or distal interphalangeal joints or under the MT heads. An MT off-loading insole can also be used to alleviate symptoms following lesser toe deformities. Morton's neuroma is a benign neuroma of an intermetatarsal plantar nerve that leads to a painful condition affecting the MT area. The MT bar, the plantar pad, or a more cushioned insole would be useful. In addition, patients with any of the above various forefoot disorders should avoid tight-fitting or high-heeled shoes. Applying an insole or orthosis and wearing proper shoes can be beneficial for managing forefoot disorders.
ABSTRACT
Forefoot disorders are often seen in clinical practice. Forefoot deformity and pain can deteriorate gait function and decrease quality of life. This review presents common forefoot disorders and conservative treatment using an insole or orthosis. Metatarsalgia is a painful foot condition affecting the metatarsal (MT) region of the foot. A MT pad, MT bar, or forefoot cushion can be used to alleviate MT pain. Hallux valgus is a deformity characterized by medial deviation of the first MT and lateral deviation of the hallux. A toe spreader, valgus splint, and bunion shield are commonly applied to patients with hallux valgus. Hallux limitus and hallux rigidus refer to painful limitations of dorsiflexion of the first metatarsophalangeal joint. A kinetic wedge foot orthosis or rocker sole can help relieve symptoms from hallux limitus or rigidus. Hammer, claw, and mallet toes are sagittal plane deformities of the lesser toes. Toe sleeve or padding can be applied over high-pressure areas in the proximal or distal interphalangeal joints or under the MT heads. An MT off-loading insole can also be used to alleviate symptoms following lesser toe deformities. Morton's neuroma is a benign neuroma of an intermetatarsal plantar nerve that leads to a painful condition affecting the MT area. The MT bar, the plantar pad, or a more cushioned insole would be useful. In addition, patients with any of the above various forefoot disorders should avoid tight-fitting or high-heeled shoes. Applying an insole or orthosis and wearing proper shoes can be beneficial for managing forefoot disorders.
Subject(s)
Animals , Humans , Congenital Abnormalities , Foot , Foot Orthoses , Gait , Hallux , Hallux Limitus , Hallux Rigidus , Hallux Valgus , Hammer Toe Syndrome , Head , Hoof and Claw , Joints , Metatarsal Bones , Metatarsalgia , Metatarsophalangeal Joint , Neuroma , Orthotic Devices , Quality of Life , Shoes , Splints , ToesABSTRACT
Hallux valgus with metatarsus adductus is difficult to treat and has a higher risk of recurrence after correction. Some treatments for hallux valgus with metatarsus adductus have been reported, but these are extensive procedures with a risk of complications associated with the shortening and malposition of the lesser metatarsals. The technique described here is easier to perform and has several advantages over the previously reported techniques.
Subject(s)
Hallux Valgus , Hallux , Metatarsal Bones , Metatarsus , Methods , RecurrenceABSTRACT
BACKGROUND: This study aims to describe the trends in the severity and treatment modality of patients with diabetic foot ulcer (DFU) at a single tertiary referral center in Korea over the last 10 years and compare the outcomes before and after the introduction of a multidisciplinary diabetic foot team. METHODS: In this retrospective observational study, electronic medical records of patients from years 2002 to 2015 at single tertiary referral center were reviewed. Based on the year of first admission, patients were assigned to a group either before or after the year 2012, the year the diabetes team launched. RESULTS: Of the 338 patients with DFU, 229 were first admitted until the year 2011 (group A), while 109 were first admitted since the year 2012 (group B). Mean age was higher in group B, and ulcer size was larger than those of group A. Whereas duration of diabetes was longer in group B, glycemic control was improved (mean glycosylated hemoglobin, 9.48% vs. 8.50%). The proportion of minor lower extremity amputation (LEA) was increased, but length of hospital stay was decreased (73.7±79.6 days vs. 39.8±36.9 days). As critical ischemic limb increased, the proportion of major LEA was not decreased. CONCLUSION: Improved glycemic control, multidisciplinary strategies with prompt surgical treatment resulted in reduced length of hospital stay, but these measures did not reduce major LEAs. The increase in critical ischemic limb may have played a role in the unexpected outcome, and may suggest the need for increased vascular intervention strategies in DFU treatment.
Subject(s)
Humans , Amputation, Surgical , Diabetic Foot , Diagnosis , Electronic Health Records , Extremities , Glycated Hemoglobin , Korea , Length of Stay , Lower Extremity , Observational Study , Patient Care Team , Retrospective Studies , Tertiary Care Centers , UlcerABSTRACT
Unilateral absence of a pulmonary artery (UAPA) is a rare congenital anomaly that may present with various symptoms, depending on the nature and severity of other cardiovascular anomalies. Furthermore, contralateral lung surgery in patients with UAPA is extremely rare, and clinical experience is limited. This report describes a case of surgical treatment of contralateral primary lung cancer in a patient with isolated UAPA. A 56-year-old man was diagnosed with primary lung cancer accompanied by isolated UAPA on the contralateral side. He underwent meticulous cardiorespiratory function tests preoperatively. We performed a right lower lobectomy. Although in the immediate postoperative period, the patient suffered from a mild decline in his respiratory function, he recovered uneventfully. The present case shows that preoperative awareness of UAPA and meticulous perioperative management enable contralateral lung surgery to be performed safely.
Subject(s)
Humans , Middle Aged , Lung Neoplasms , Lung , Perioperative Care , Postoperative Period , Pulmonary ArteryABSTRACT
Early diagnosis followed by primary repair is the best treatment for spontaneous esophageal perforation. However, the appropriate management of esophageal leakage after surgical repair is still controversial. Recently, the successful adaptation of vacuum-assisted closure therapy, which is well established for the treatment of chronic surface wounds, has been demonstrated for esophageal perforation or leakage. Conservative treatment methods require long-term fasting with total parenteral nutrition or enteral feeding through invasive procedures, such as percutaneous endoscopic gastrostomy or a feeding jejunostomy. We report 2 cases of esophageal leakage after primary repair treated by endoscopic vacuum therapy with continuous enteral feeding using a Sengstaken-Blakemore tube.